Seasonal Benefits Plan
Your JBT benefits include comprehensive dental coverage for you and your eligible children.
The plan pays a set amount for each covered dental procedure. This is called the scheduled allowance.
You need to meet an annual deductible before the plan pays benefits, and there is an annual maximum benefit.
How the Plan Works
|Dental providers||JBT contracts with Arrin dental network providers, who agree to accept JBT’s scheduled allowance for procedures as payment in full.
If you use an out-of-network dentist, you are responsible for paying the difference between the scheduled allowance for a procedure and the cost billed by the dentist.
Your dentist can use this dental claim form or any other dental claim form to file a claim or submit a request for preauthorization.
|Cost sharing between you and the plan||Annual deductible (what you pay before the plan starts sharing costs): $50 individual/$100 family.
Calendar-year maximum benefit: $1,600 per individual.
Network provider: After you meet your annual deductible, the plan pays the scheduled allowance for your procedure, up to the annual maximum. You are responsible for amounts over the annual maximum.
Out-of-network provider: You are responsible for paying any amount over the scheduled allowance for a procedure. You are also responsible for amounts over the annual maximum.
|Allowance schedule for frequently used services||Dental checkups (two per calendar year): $60.
X-ray: $108 complete set.
Filling (single surface): $81 (amalgam); $92 (resin).
Inlay restoration (one surface): $324 (metallic); $265 (porcelain/ceramic).
Replacement inlay: $59.
Crown: $281 (resin).
Replacement crown: $59.
Root canal: $373 (front); $448 (bicuspid); $562 (molar).
Review the full table of scheduled allowances for covered dental procedures.
Will your dental treatment cost more than $500? Ask your dentist to request preauthorization on a dental claim form before you receive care.
Need a network dentist?Find one here
JBT’s vision benefit provides coverage for standard eye exams and glasses or contact lenses for you. Your children are not covered.
You will pay discounted rates for covered vision services when you see a Vision Service Plan (VSP) Advantage Network provider. Although you can go to any eye doctor you choose, you will pay less when you see an in-network eye doctor or optician (a person who manufactures and dispenses glasses and contact lenses).
How the Plan Works
|Vision providers||VSP providers: You may save money when you use a Vision Service Plan (VSP) Advantage Network provider. After you pay a $10 copay, the plan pays 100% of the exam and an allowance for frames and lenses. The plan also offers discounts and savings on other services not covered by the vision plan.
Out-of-network provider: If you use an out-of-network eye doctor or optician, you are responsible for paying the difference between the fees billed by the provider and an out-of-network allowance set by VSP. Call VSP at 800-877-7195, or go to the VSP website for details.
|What you pay for frequently used services||WellVision eye exam (1 every 12 months): $10 copay.
Eyeglass frames (1 every 24 months): $0 after exam copay, up to $180 allowance, and 20% discount on the amount over the allowance.
Eyeglass lenses (1 pair every 12 months):